In the media, in court cases, on the Internet, and in child welfare agencies, there is much confusion about Reactive Attachment Disorder (RAD) and an unrecognized, fad diagnosis with a similar name that often poses as RAD.

Reactive Attachment Disorder (RAD)

RAD is a recognized diagnosis which is defined in the Diagnostic and Statistical Manual (DSM-IV-Tr) of the American Psychiatric Association (it is essentially unchanged in the DSM-V). RAD is considered an "uncommon" disorder (code 313.89) which follows children's experiences of extreme neglect or abuse and which is expressed in one of two ways in while children react to extreme neglect and/or abuse in one of two ways:

Markedly disturbed and developmentally inappropriate social relatedness in most contexts, as evidenced by either of two behaviors:

Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses...

In other words, children with RAD have experienced extreme social and emotional conditions and have become either very withdrawn and clingy or more friendly with unfamiliar people than we would expect of children their age. While there is no validated therapy specifically for RAD, many experts recommend gentle, patient, consistent and responsive parenting for these children, as for all children with special emotional needs. This disorder can be diagnosed while the child is five years of age or younger; as children get older, their behavior matures and changes in ways that make attachment problems much less evident.

Foster Cline, MD, the Colorado psychiatrist who popularized Attachment Therapy, is also credited with inventing AD, the unrecognized diagnosis used nearly exclusively by Attachment Therapists. Decades of vigorous marketing of this fad diagnosis to parents and child welfare agencies has positioned it as a dreaded disorder of adopted and foster children, as well as a path to eligibility for "special needs" subsidies.

Proponents of the AD diagnosis frequently refer to it as "RAD," leading to public confusion about the two, but the two are conceptually very different. There is suspicion that Attachment Therapists who treat problems they have diagnosed as AD will charge insurance companies for treating RAD; because AD is not a legitimate diagnosis, its treatment would not be reimbursed by public or private insurers.

Rather than meeting the criteria for behaviors that would receive the RAD diagnosis, the AD diagnosis is characterized by a laundry list of behaviors, making it a typical catch-all "diagnosis" of the sort commonly identified with quack practices. Many of the so-called "symptoms" are extremely violent behaviors; some are normal for certain age groups; and even good behavior can be interpreted and reframed as a child "stalking his prey." The AD diagnosis contains a number of internal contradictions, as when children are said to lack empathy but yet they are believed able to understand people well enough to be clever manipulators and triangulate adults. Likewise both eye contact, or lack of it, are considered problematic AD signs.

Practitioners using the AD model warn parents and prospective parents that if a child does not exhibit all the signs associated with AD he is likely to develop them in the future if not treated with Attachment Therapy/Parenting. Lists of AD signs have been called “wildly inclusive” and commonly include the following.

Only two of these signs ("indiscriminately affectionate with strangers" and "inappropriately demanding and clinging") are consistent with the description of RAD in DSM-IV.

Attachment Therapists also claim children diagnosed with AD are capable of being sexual predators, with the potential to become serial killers as adults. AD has been referred to as "Ted Bundy Disease."

Because of the possible role of this belief in promoting child abuse, it is most disturbing to see among characteristics attributed to children diagnosed with AD the supposed inability to feel pain (while being overly sensitive to light touch).

A discussion of AD and RAD is included in the 2006 Report on Attachment Therapy by the American Professional Society on the Abuse of Children (APSAC). The task force that authored this report remarked on the tendency to over-diagnosis a “rare” condition such as RAD, plus the problem of the highly inclusive lists of AD criteria:

Clearly, these lists of nonspecific problems extend far beyond the diagnostic criteria for RAD and beyond attachment relationship problems in general. These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain. Posting these types of lists on Web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders.It is easy to see that any child is likely to be labeled as AD when concerned parents consult with an Attachment Therapist. AD is considered a common condition by its proponents. The diagnosis clearly demonizes adopted and foster children, making parents fearful and suspicious of even normal child behaviors. It sets up a situation where harsh parenting is perceived as justified to head off a child's disastrous future.

Attachment Therapists claim that AD is foundational for a number of other disorders, and that AD must therefore be treated first, and by a practitioner who is committed to the AD concept. They may diagnose AD with the use of any of several unvalidated checklists, such as the Randolph Attachment Disorder Questionnaire (RADQ) , the Attachment Disorder Symptom Checklist, Walter Buenning’s Infant and Child Symptom Checklists, and the Evergreen Consultants Check List.

Some parents charged with criminal child abuse have tried to convince juries that their children had AD. As Jean Mercer, PhD — leading critic of Attachment Therapy — commented, "The RAD defense is regrettably becoming more common as a way to extricate abusive, even homicidal, parents from legal difficulties." In a blame-the-child defense strategy, AD is portrayed as a disorder so severe that it would unhinge the most loving of parents.

Journalists don't help to clarify the situation for the public. They rarely question the AD diagnosis — or even consult the DSM — but rather parrot the portrayal of adopted children as "monsters at home."

NOTE: APSAC & the American Psychological Association’s Division on Child Maltreatment recommend that child welfare workers investigate where AD has been diagnosed.